Healthcare Provider Details

I. General information

NPI: 1689055931
Provider Name (Legal Business Name): THOMAS S KOLLODGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W STOUT ST
RICE LAKE WI
54868-5000
US

IV. Provider business mailing address

25 JOHNSON AVE
DILLON MT
59725-3323
US

V. Phone/Fax

Practice location:
  • Phone: 715-236-8100
  • Fax:
Mailing address:
  • Phone: 406-683-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3435
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3395
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-OPT-LIC-4926
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: